Midfacial growth after costochondral graft construction of the mandibular ramus in hemifacial microsomia.
OBJECTIVE
The purpose of this study was to document vertical midfacial growth after costochondral graft mandibular ramus construction in children with type IIB and type III hemifacial microsomia (HFM).


METHODS
This is a retrospective study of 33 children who underwent costochondral graft (CCG) construction for mandibular type IIB (abnormal, small, and medially displaced ramus, n = 19) and mandibular type III (absent ramus and glenoid fossa, n = 14) HFM, between 1980 and 1990. Types I and IIA patients were not included because their milder mandibular deformities were lengthened by osteotomy. Mean age at operation was 6.2 (2 to 10) years, and the mean follow-up period was 5.5 (1 to 13.5) years. Occlusal cant, piriform angle, and intergonial angle were measured on the most current posteroanterior (PA) cephalogram. The ratio of unaffected to affected ramus length was determined on the most current panoramic radiograph. Patient outcomes were classified based on the occlusal cant at the latest follow-up: group 1, successful result with a symmetrical maxilla (occlusal cant of <5 degrees); group 2, acceptable result (occlusal cant > or =5 degrees but <8 degrees), and Group 3, failure (occlusal cant > or = 8 degrees). OMENS scores were calculated for each patient: each of the five major anatomic deformities of HFM (orbital, mandibular, auricular, neural, and soft tissue) were graded 0 to 3 and summed. The mean differences in age at operation and OMENS scores between groups were calculated (ANOVA).


RESULTS
At the end of follow-up, patients defined as having a successful result (group 1) had a mean occlusal cant of 2 degrees, a mandibular length ratio of 1.0, and an intergonial angle of 2 degrees. However, the final piriform angle was 7 degrees, indicating less vertical midfacial growth than maxillary alveolar growth. These patients were older at the time of operation (mean age, 6.7 years), and their mean OMENS score (6.3) was significantly lower (P = .004) than in patients in group 2 (mean age at operation, 6.3 years; mean OMENS score, 6.8) and group 3 (mean age at operation, 5.8 years; mean OMENS score, 7.8). In group 2, the occlusal cant, mandibular length ratio, and intergonial and piriform angles did not improve. In group 3, the occlusal cant and piriform angle became worse during the follow-up period.


CONCLUSIONS
The results of this study indicate that after construction of the ramus and condyle in type IIB and III HFM patients, vertical midface growth is secondary to a combination of midfacial and alveolar growth. Patients operated on at an older age were more likely to have a successful long-term result. Finally, the severity of the overall deformity, as reflected in a higher OMENS score, appeared to be an important factor in the response to early correction.
Padwa
B L
BL
Children's Hospital, Boston, MA 02139, USA.
Mulliken
J B
JB
Maghen
A
A
Kaban
L B
LB
D000367:Age Factors; D000704:Analysis of Variance; D016025:Bone Transplantation / Q000379:methods*; D002356:Cartilage / Q000637:transplantation; D002648:Child; D005146:Facial Asymmetry / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008334:Mandible / Q000254:growth & development / Q000601:surgery*; D008445:Maxillofacial Development; D012189:Retrospective Studies; D012272:Ribs / Q000637:transplantation; D012720:Severity of Illness Index; D017211:Treatment Failure; D016896:Treatment Outcome; D014716:Vertical Dimension